Transient ischemic attack medical therapy: Difference between revisions

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Latest revision as of 00:29, 30 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S [2]

Overview

Medical therapy for the management of transient ischemic attack includes emergency or early assessment and long term management to prevent future risk of stroke.^[1] ^[1]

Medical Therapy

The approach to medical management of patients with transient ischemic attack may involve the following:^[1]
a) Early assessment and emergency management
b) Long term management and follow up

Early assessment and emergency management

Rapid transport to the hospital
History and examination
IV access
Fingerstick glucose to rule out hypoglycemia
EKG testing to rule out ongoing ischemia
Neuroimaging to rule out infarction

Risk assessment and management plan

After initial evaluation of patient, the decision to further manage the patient in the emergency department observation unit, hospital admission or outpatient follow up depends on no of factors which may include

ABCD2 scoring(AHA guidelines)
Assessment by emergency physician
Opinion of neurologist
Risk of future stroke or TIA
Patient preference
Local resources

Guidelines for the hospitalization of patients with TIA

AHA guidelines

ABCD2 score of 3
ABCD2 score of 0-2 and uncertainity of completion of work up in 2 days in outpatient
ABCD2 score of 0-2 and other evidence suggesting patient's transient ischemic attack may be caused by focal ischemia

NSA guidelines

24-48 hours

Hospitalization recommended for early t-PA availability in case of recuurent attack or infarction
Early risk assessment and management plan

<1 week
Hospitalization in less than a week of TIA may be recommended in following situations:

Symptoms >1 hour
Known hypercoaguable disorder
Symptomatic internal carotid artery stenosis>50
Two or more TIAs per week (crescendo TIA)
Cardiac source of embolism (atrial fibrillation)
California and ABCD2 suggesting admission

Pharmacological therapy

Hypertension

Blood pressure control may be considered in patients with evidence of end organ damage or levels above 220/120mmHg
Blood pressure autoregulation without medication may be considered in patients with increased levels in patients with TIA to enhance cerebral perfusion^[1]

Non cardioembolic TIA

Antiplatelet therapy is recommended as first line.^[1]
Aspirin 50-325mg/day, combination of aspirin and extended release dipyridamole and clopidogrel may be considered first line treatment.
Aspirin and clopidogrel may be started within 24 hours of minor stroke or TIA and may be continued for 21 days.

Cardioembolic TIA

Anticoagulation may be recommended in patients with known cardiac source of emboli such as atrial fibrillation and acute MI with ventricular thrombus^[1]
Anticoagulation therapy with warfarin may be recommended with target INR 2-3
Aspirin 325mg may be recommended in patients unable to take anticoagulants

Long Term management

Long term management mainly depends on the modification of underlying risk factors:^[1]

Control of Blood pressure to <140/90mmHg with ACE inhibitors or Angiotensin receptor blockers or both
Blood sugar control <126 mg/dl with antidiabetics
Treatment of hyperlipidemia with statins
Anticoagulant and antiplatelets for underlying cardiac disease.

References

↑ ^1.0 ^1.1 ^1.2 ^1.3 ^1.4 ^1.5 ^1.6 Albers GW, Hart RG, Lutsep HL, Newell DW, Sacco RL (1999). "AHA Scientific Statement. Supplement to the guidelines for the management of transient ischemic attacks: A statement from the Ad Hoc Committee on Guidelines for the Management of Transient Ischemic Attacks, Stroke Council, American Heart Association". Stroke. 30 (11): 2502–11. PMID 10548693.

Template:WH Template:WS

[pmid10548693-1] 1.0 ^1.1 ^1.2 ^1.3 ^1.4 ^1.5 ^1.6 Albers GW, Hart RG, Lutsep HL, Newell DW, Sacco RL (1999). "AHA Scientific Statement. Supplement to the guidelines for the management of transient ischemic attacks: A statement from the Ad Hoc Committee on Guidelines for the Management of Transient Ischemic Attacks, Stroke Council, American Heart Association". Stroke. 30 (11): 2502–11. PMID 10548693.

[1]

@@ Line 1: / Line 1: @@
 __NOTOC__
 {{Transient ischemic attack}}
-{{CMG}}
+{{CMG}}{{AE}}{{AA}}
+==Overview==
+Medical therapy for the management of transient ischemic attack includes emergency or early assessment and long term management to prevent future risk of stroke.<ref name="pmid10548693">{{cite journal| author=Albers GW, Hart RG, Lutsep HL, Newell DW, Sacco RL| title=AHA Scientific Statement. Supplement to the guidelines for the management of transient ischemic attacks: A statement from the Ad Hoc Committee on Guidelines for the Management of Transient Ischemic Attacks, Stroke Council, American Heart Association. | journal=Stroke | year= 1999 | volume= 30 | issue= 11 | pages= 2502-11 | pmid=10548693 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10548693  }} </ref>
+<ref name="pmid10548693">{{cite journal| author=Albers GW, Hart RG, Lutsep HL, Newell DW, Sacco RL| title=AHA Scientific Statement. Supplement to the guidelines for the management of transient ischemic attacks: A statement from the Ad Hoc Committee on Guidelines for the Management of Transient Ischemic Attacks, Stroke Council, American Heart Association. | journal=Stroke | year= 1999 | volume= 30 | issue= 11 | pages= 2502-11 | pmid=10548693 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10548693  }} </ref>
 ==Medical Therapy==
-The mainstay of treatment following acute recovery from a TIA should be to diagnose and treat the underlying cause.  It is not always immediately possible to tell the difference between a CVA (stroke) and a TIA.  Most patients who are diagnosed at a hospital's [[Emergency department|Accident & Emergency Department]] as having suffered from a TIA will be discharged home and advised to contact their primary physician to organize further investigations.
+The approach to medical management of patients with transient ischemic attack may involve the following:<ref name="pmid10548693">{{cite journal| author=Albers GW, Hart RG, Lutsep HL, Newell DW, Sacco RL| title=AHA Scientific Statement. Supplement to the guidelines for the management of transient ischemic attacks: A statement from the Ad Hoc Committee on Guidelines for the Management of Transient Ischemic Attacks, Stroke Council, American Heart Association. | journal=Stroke | year= 1999 | volume= 30 | issue= 11 | pages= 2502-11 | pmid=10548693 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10548693  }} </ref><br>
+a) Early assessment and emergency management <br>
+b) Long term management and follow up
+===Early assessment and emergency management===
+*Rapid transport to the hospital
+*History and examination
+*IV access
+*Fingerstick glucose to rule out hypoglycemia
+*EKG testing to rule out ongoing ischemia
+*Neuroimaging to rule out infarction
+===Risk assessment and management plan===
+After initial evaluation of patient, the decision to further manage the patient in the emergency department observation unit, hospital admission or outpatient follow up depends on no of factors which may include
+*ABCD2 scoring(AHA guidelines)
+*Assessment by emergency physician
+*Opinion of neurologist
+*Risk of future stroke or TIA
+*Patient preference
+*Local resources
+===Guidelines for the hospitalization of patients with TIA===
+====AHA guidelines====
+*ABCD2 score of 3
+*ABCD2 score of 0-2 and uncertainity of completion of work up in 2 days in outpatient
+*ABCD2 score of 0-2 and other evidence suggesting patient's transient ischemic attack may be caused by focal ischemia
-The initial treatment is Aspirin, second line is clopidogrel, third line is ticlopidine.  If TIA is recurrent after Aspirin treatment, the combination of Aspirin and dipirydamole is needed (Aggrenox).
+====NSA guidelines====
+'''24-48 hours'''<br>
+*Hospitalization recommended for early t-PA availability in case of recuurent attack or infarction
+*Early risk assessment and management plan
+'''<1 week'''<br>
+Hospitalization in less than a week of TIA may be recommended in following situations:
+*Symptoms >1 hour
+*Known hypercoaguable disorder
+*Symptomatic internal carotid artery stenosis>50
+*Two or more TIAs per week (crescendo TIA)
+*Cardiac source of embolism (atrial fibrillation)
+*California and ABCD2 suggesting admission
-Some patients may also be given modified release [[dipyridamole]] or [[clopidogrel]].
+===Pharmacological therapy===
+====Hypertension====
+*Blood pressure control may be considered in patients with evidence of end organ damage or levels above 220/120mmHg
+*Blood pressure autoregulation without medication may be considered in patients with increased levels in patients with TIA to enhance cerebral perfusion<ref name="pmid10548693">{{cite journal| author=Albers GW, Hart RG, Lutsep HL, Newell DW, Sacco RL| title=AHA Scientific Statement. Supplement to the guidelines for the management of transient ischemic attacks: A statement from the Ad Hoc Committee on Guidelines for the Management of Transient Ischemic Attacks, Stroke Council, American Heart Association. | journal=Stroke | year= 1999 | volume= 30 | issue= 11 | pages= 2502-11 | pmid=10548693 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10548693  }} </ref>
+====Non cardioembolic TIA====
+*Antiplatelet therapy is recommended as first line.<ref name="pmid10548693">{{cite journal| author=Albers GW, Hart RG, Lutsep HL, Newell DW, Sacco RL| title=AHA Scientific Statement. Supplement to the guidelines for the management of transient ischemic attacks: A statement from the Ad Hoc Committee on Guidelines for the Management of Transient Ischemic Attacks, Stroke Council, American Heart Association. | journal=Stroke | year= 1999 | volume= 30 | issue= 11 | pages= 2502-11 | pmid=10548693 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10548693  }} </ref>
+*Aspirin  50-325mg/day, combination of aspirin and extended release dipyridamole and clopidogrel may be considered first line treatment.
+*Aspirin and clopidogrel may be started within 24 hours of minor stroke or TIA and may be continued for 21 days.
+====Cardioembolic TIA====
+*Anticoagulation may be recommended in patients with known cardiac source of emboli such as atrial fibrillation and acute MI with ventricular thrombus<ref name="pmid10548693">{{cite journal| author=Albers GW, Hart RG, Lutsep HL, Newell DW, Sacco RL| title=AHA Scientific Statement. Supplement to the guidelines for the management of transient ischemic attacks: A statement from the Ad Hoc Committee on Guidelines for the Management of Transient Ischemic Attacks, Stroke Council, American Heart Association. | journal=Stroke | year= 1999 | volume= 30 | issue= 11 | pages= 2502-11 | pmid=10548693 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10548693  }} </ref>
+*Anticoagulation therapy with warfarin may be recommended with target INR 2-3
+*Aspirin 325mg may be recommended in patients unable to take anticoagulants
+===Long Term management===
+Long term management mainly depends on the modification of underlying risk factors:<ref name="pmid10548693">{{cite journal| author=Albers GW, Hart RG, Lutsep HL, Newell DW, Sacco RL| title=AHA Scientific Statement. Supplement to the guidelines for the management of transient ischemic attacks: A statement from the Ad Hoc Committee on Guidelines for the Management of Transient Ischemic Attacks, Stroke Council, American Heart Association. | journal=Stroke | year= 1999 | volume= 30 | issue= 11 | pages= 2502-11 | pmid=10548693 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10548693  }} </ref>
+*Control of Blood pressure to <140/90mmHg with ACE inhibitors or Angiotensin receptor blockers or both
+*Blood sugar control <126 mg/dl with antidiabetics
+*Treatment of hyperlipidemia with statins
+*Anticoagulant and antiplatelets for underlying cardiac disease.
 ==References==
 {{reflist|2}}
 {{WH}}
 {{WS}}
@@ Line 19: / Line 75: @@
 [[Category:Disease]]
 [[Category:Emergency medicine]]
-[[Category:Primary care]]
 [[Category:Needs overview]]
+[[Category:Needs content]]